Scientific Papers

Conceptualizing a less paranoid schizophrenia | Philosophy, Ethics, and Humanities in Medicine

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Underlying axioms and paradigmatic blind spots

Although there is room to debate many of his specific points and inferences, Foucault (1965) addressed many of the genealogical ideas that underlie current mental health practice. Salient are the social and moral implications of mental illness in a post-enlightenment age. Reason and empiricism were held up as the means by which humanity would extract itself from the arbitrary and oppressive moral and social systems that characterized the preceding epochs. However, as no human or society can exist without an orienting value system (ought from is) [30], this revolution merely altered the parameters. Moral punishment became reserved for “healthy” individuals with deviant behavior, while those whose behavior was determined to be medical in origin were to be cured (i.e. brought back to reason and regulated passions). However, in both cases it was deviance from the collectively understood “good” which was targeted. In the former case, deviant behavior was punished or corrected through learning, while in the latter psychological deviance imbued society with a moral duty to treat or cure. Much of our current approach to treatment, such as cognitive-behavioral theory, is predicated on this idea, that it is irrational thoughts that cause distress, based on the underlying assumption that showing the person that their thinking is irrational is itself a kind of cure for their experience.

In a recent review of 30 consecutive court-mandated medication hearings, 29 were approved without a jury, most in cases where serious neurological damage had been caused by medications and at higher doses than would be recommended. All cases of treatment had entirely discounted options such as psychotherapy, despite defendant and family protest, demonstrating that the line between moral capability, medical impairment, and societal responsibility is still quite blurry [5].

The presenting issues involving psychosis are inherently aberrant against the axioms of the age, giving their expression a numinous quality absent from comparable symptomology. While a “healthy” person can empathize with a depressive or obsessional person (seeing their experience as merely an extreme version of their own), the hallucinations, delusions, disorganized thoughts, and behaviors of psychosis are deeply unsettling. Such a person may be pitied or sympathized with, but how can one empathize with a person who is not participating in consensus reality, let alone take their perspective seriously?

The rational-empirical model Foucault was dissecting had more comprehensive effects as well, establishing the parameters by which reality was defined. Truth was to be determined through careful observation, data collection, and objective analysis of results. One could subsequently remove the confounds of arbitrary values and subjectivity and determine what was and was not “real.” This idea has been one of the most important and useful tools in human history, and its benefits cannot be overstated; however, as with any idea, it rests upon axioms and results in outcomes with predictable constraints.

As much of the unspoken paradigm scaffolding within scientific models can be traced back to the ideas of rationalism and empiricism, and to the extent this paper aims to address axiomatic flaws in those models, it is worth exploring the concepts. Broadly speaking, the rationalists argued that knowledge was attained through logic and reason and that human understanding was founded on innate ideas. In contrast, the empiricists argued that humans were tabula rasa, and that knowledge was gained exclusively through sensory experience. Responding to both, Kant [31] outlined his synthetic a priori propositions on reason and its recognition of necessary cognitive structures preceding sensory modification. He argued that the only way in which a human being could have knowledge in a functionally infinite sea of data was through categorization. That we contained an innate scaffolding which predisposed us to select and judge our sensory data, and that without such we could not possibly perceive the world in any meaningful way at all. Moreover, as we were goal-oriented creatures, this was an inherently value-laden conceptualization. While this perspective was revolutionary in overall enlightenment thinking, its ultimately phenomenological approach to reality has had little impact on the scientific endeavor to understand that very rationality.

What has been retained is something of the desire which drove Kant’s deductive exploration; namely to arrive at a surety of knowledge without call to a divine authority. His endeavors into synthetic a priori knowledge assumed and ultimately sought to prove that foundational sure knowledge could be found and worked upwards from to arrive at universal and objective truth. The distillation of this is the reductionism which subtly underlies scientific inquiry to this day; the belief that the best way to understand a complex system is to break it into its smallest constituent units and then extrapolate upwards. From this we may identify the roots of the atomism and materialism which will be discussed further in this paper.

Equally important to these methodological axioms however is the subtle implications of a unitary truth when applied to the psyche and its inquires (i.e. that a single correct perspective is attainable and thus deviation therefrom is an error to be corrected). Through this lineage one has dispensed with subjectivity (the valuing ‘ought’ and its many constraints) in favor of objective proxies as a means of study and have thus over time, often with a sense of moral duty, come to see subjectivity as (at best) epiphenomenal. This trend has likely reinforced, if not outright caused, the current preference for biological interventions for subjective experiences while viewing aberrant subjectivities as a problem to be solved. The more strictly empirical approach can likely be attributed to the structural disconnect between verifiable data and subjective experience endemic to objective and materialistic approach to science; however, this inattention has created potential blind-spots in investigative assumptions.

Congruent models and fractal patterns

While Kant arrived at his categorical phenomenological conclusions from deduction and intuition, Jean Piaget [32] outlined a nearly identical process by observing the developmental construction of schemata in young children. In highlighting the evolution of children’s reports and understandings of reality, Piaget stands as a kind of naturalist of the same process proposed by Kant, in which a rather simple set of structures give rise over time to the operations of intelligence. In both Kant’s concept of understanding and Piaget’s concept of a schema (in a total sense), a person can only conceive of realities congruent with the structure of their framework,that is, they have a subjective perspective. Where Piaget’s observations stand out is in his detailing of the process by which these structures update and organize themselves across time (e.g. the famous cognitive revolution children experience when developing a theory of mind). In light of contemporary evolutionary, genetic, and personality research though, the full scope of potential schematic diversity remains an open question. That is, to what degree do we converge upon a universal perception of reality and to what degree are we perceiving and conceptualizing differently?

Regardless, the implication of the symptom-focused taxonomy of the DSM or ICD is that subjective diversity is either irrelevant or non-existent and thus our scientific study of the mind cannot account for it. Given that our schemata expand and evolve through assimilation and accommodation, and that they are the medium through which we construct our reality, the means by which that dynamic equilibrium is affected by biological predisposition and the specific nature of events experienced during this process must be accounted for if psychology is to succeed as a scientific pursuit. Understanding the forces which led to and maintain such an equilibrated structure carries implications for psychological models of cognition and perception as well as for clinical treatment.

Symmetrical to Piaget’s schemata, Kuhn’s [33] description of the paradigmatic nature of scientific discovery demonstrates this process at the level of consensus reality and may also indicate the core problem with current models of schizophrenia-spectrum disorders. Much in the same way a developing child in Piaget’s model works pragmatically within a ‘good enough’ schema until sufficient development and anomalous information induces a reorganizational (and thus perceptual) classification, Kuhn noted that scientific paradigms (collective schemata of interpretation and behavior) progress until sufficient anomalous data induces a reorganization of core assumptions, such that previous evidence and anomalous evidence remain, are accounted for, and explained. Much as two individuals with incompatible schemata would find mutual understanding impossible without accommodation on one or both ends, the current paradigms informing much of psychological research (e.g. objectivism, materialism, etc.) cannot account for the symptomatic manifestations of the schizotypal spectrum other than as pathological deviation, and thus remain obtusely focused. Instead, models must account for the biological and environmental impacts on schematic development as a necessary component in any defensible definition of mental health. Currently, models such as the Five-Factor Model of personality (FFM); [34] offer avenues to begin exploring and discussing this scientifically, however their implications have yet to meaningfully propagate throughout the psychological field.

Outcomes and limitations of unexamined axioms

In a discussion on the theoretical challenges facing psychology today, Slife (as cited in Lambert, 2004) identified numerous constraints on theory and its practical application. Objectivism essentially posits that the logic inherent in the methods and techniques of science and clinical practice can be relatively free of systematic biases and values. This is achieved through the use of logical reasoning (rationalism) and unbiased observation of phenomena (empiricism). This permits a certain unbiased standard of proof that can be verified and agreed upon without appeal to arbitrary authority or preconceived assumptions; however, it also leads to limitations. It bounds what can be studied (and thus proven) to those things which can be observed and replicated. In psychology, this translates to examining the psyche by proxy. As one can have no direct observation of experience, various behaviors are examined instead with the assumption that these act as indicators of internal states and dynamics. Where behaviors cannot be determined, states are operationalized; anxiety becomes the nexus of racing thoughts, restlessness, distractibility, etc. What cannot be captured is the valence, meaning, and experience of anxiety, or the idiosyncratic relationships an individual’s anxiety has with their own history, conceptual framework, and day-to-day experience.

For example, within a psychodynamic framework, a clinician would find it important to determine whether a patient’s depression was anaclitic or introjective, thus accounting for the inner subjectivity underlying the overall state. However, most strictly empirical research and certainly most pharmacological research must measure itself by symptom reduction within the DSM criteria of depression, which does not account for personality style. In this way, the methods by which research is conducted systemically deem irrelevant domains of human experience and psychological evolution, becoming blind to them.

A second axiom is materialism, which posits that psychological experiences will eventually be shown to have observable and biological bases. All psychology is simultaneously biology. As with objectivism, this assumption is predominantly benign or beneficial; however, it too creates complications. One is the implicit causal direction; that the core problem is contained within, and thus solvable and explicable through, biology. Indeed, materialism is tightly wedded to objectivism as it is often far easier to study physical systems than social or psychological ones. This belief underlies much of the faith in and reliance on pharmaceuticals as “cures” for psychological disorders. Once a biological correlation is identified, it is treated as the cause despite our knowledge that the relationship is more complicated; moreover, the entire DSM/ICD classification systems assume biologic etiology. This causal direction also promotes an aura of preeminence to biological markers over holistic biopsychosocial assessment. For example, if research finds that serotonin differences act as a biomarker of depression, it is assumed that such differences causally precede the psychological state and so become the target of treatment, despite evidence that such neurotransmitters are themselves greatly influenced by environment and cognitive framing [35, 36].

Finally, the axiom of atomism assumes that the qualities of people are contained within the individual, and so treatment should focus on individual cognition, biology, and behavior. As can be seen, atomism dovetails seamlessly with reductionism (the individual is the indivisible member of the collective), materialism (the biological operations of others do not influence those around them), objectivism (it is easiest to observe the components of an individual rather than the network of influences between them and their environment over time) and implicit morality (the locus of choice and thus moral human agency exists within the individual). These assumptions, while almost certainly a necessary heuristic, can lead researchers and practitioners to underestimate or ignore the impact of relationship factors or social context.

These and other axioms inform many more areas of human life than the field of psychology, and in many of them (e.g. particle physics), they may operate more or less perfectly. Inasmuch as psychology is to be the study of the psyche, however, it must at some point include the study of human subjectivity; moreover, it is the experience of suffering that we aim to alleviate, not its proxies. This is decidedly difficult within a framework that goes to great lengths to remove all subjectivity before even beginning its search.

Furthermore, whatever it is one means by the psyche, it is a dynamic and multi-level phenomenon. It is shaped by the past through memories and biological alterations (processes which continue to change throughout the lifetime); simultaneously, how a person conceives of the future continuously alters behaviors, cognitions, and relationships (which in turn recontextualizes memories and alters biology). Each of these is further informed by the idiosyncratic relationships a person has (as well as how he conceives of them) and the environment in which he lives (physical and social). It is in fact this entire set of inter-penetrating and interlocking systems which determine how any particular experience manifests. Within the framework above, those elements which are most difficult to operationalize or which lie perpendicular to accepted rigor are granted a reality significantly less substantial than those which are considered more “evidence-based,” and thus most often lay unaccounted for in final etiology and nosology.

The DSM’s taxonomy, as well as its preeminence in mental health practice, is the distillation of this process. It testifies to the strengths this approach has brought to the field, and simultaneously contains its weaknesses. As has been noted by clinicians throughout its development and subsequent iterations, the DSM’s approach dispenses with, misinterprets, or lies contrary to the bulk of historical and contemporary clinical wisdom [37,38,39,40].

Without an explicit definition or discussion of mental health, the DSM implies that the removal or reduction in stated symptoms is the goal (empiricism and reductionism). This creates the following three issues: (1) While symptom relief may be desired, no other medical professional would equate symptom reduction with a cure. (2) The DSM can offer no discussion or guidance on important qualia within those symptoms (e.g. recall objectivism—is the depressive experience fundamentally anaclitic or introjective). (3) The DSM offers no insight on the depth of, interactions between, or potential functions of experiences as outlined. One may contend that none of these was meant to be the function of the DSM, which was instead intended to be one tool in an arsenal the clinician would bring to bear. However, whether due to the constraints of time and energy, the demands of insurance companies, the limitations of training, the (above-outlined) biased nature of research, the fact that the DSM is subservient to the ICD, or any combination of these factors, it is often the case that the DSM is used in exactly this manner. In 2013, the National Institute of Mental Health (NIMH) ceased funding DSM-based research citing the model’s overall “lack of validity” (Insel, as cited in [41], p. 522).

The weight of evidence accrued even within this framework calls its assumptions into question. It has been noted, for example, that in clinical settings, depression is usually paired with anxiety and somatic symptoms, while also manifesting in highly variable ways (aggression, risk-taking behaviors, etc.) [39]. Simple diagnosis is insufficient for treatment planning [42] and ultimately leads to stereotyped and imprecise responses; moreover, if disorders were, in fact, distinct categories, one should expect them to have distinct boundaries with matched biological correlations. However, antidepressant medications are used to treat anxiety and other mood disorders, and antipsychotic agents are prescribed for bipolar disorder and various severe personality disorders. Symmetrically on the treatment side, cognitive-behavioral therapy (developed to address internalizing disorders) has since expanded to encompass nearly every class of mental disorder [43], despite major methodological flaws in the research that supports CBT [44]. Moreover, longitudinal and epidemiological evidence indicates that etiology, prognosis, and even pharmaceutical effectiveness depend on psychosocial factors disregarded in the current taxonomy. For example, in patients with schizotypy and psychosis, treatment and pharmacological outcomes depend much more on factors such as childhood trauma, social factors, and neurocognition [3, 11, 45].

While the full impact of this dynamic stretches throughout the whole of psychology, select points are particularly relevant. In striving toward the objectivity so highly valued under our society’s ruling metanarrative, psychological practice and research has adopted, almost axiomatically, a “disease” model of psychological suffering; we document symptoms and attempt to place them into distinct categories which would have distinct biological/behavioral underpinnings which can be discretely addressed. Thus, the experience of a disorder and its treatment can be generalized and divided into discrete components. It also implies that, as the symptom expressor, the problem lies within the individual and so must be addressed at that level. As was outlined through underlying Enlightenment philosophies earlier, these assumptions are natural outcomes; that the moral locus lies within the individual’s own rationality (their claim to full personhood) and so remains unquestioned within most research models. As Higgs [18] purported, “the advancement of neoliberal values and policies likewise favors naturalizing inequality through the lens of biology, locating the suffering caused by social problems within individual bodies, which are perceived as self-contained and (ideally) fully independent” (p. 138).

Given that such a model is conducive to research, conforms well to the needs of insurance and pharmaceutical companies, and carries the implied authority of decades of acceptance, the situation is self-reinforcing. Moreover, the taxonomic model implies a baseline human experience, deviation from which constitutes the nature of psychopathology. Given biologization and atomism, the problem is seen as localized within the person, and treatment focuses on the adjustment of biological systems and the resolution of irrational thoughts and behaviors. In so doing, the complexity of human psychology and the entirety of subjectivity is done away with; a serious issue given that the psyche is defined by and experienced through subjectivity. Indeed, “a grisly tradition of ‘biologizing social facts’ exists within psychiatry” [18], p. 137–138). This divides much of psychology as a body of knowledge from the bulk of clinical wisdom and makes the training, expansion, and transmission of this understanding difficult at best. It limits the field’s understanding of human psychology and our ability to address individuals’ actual experiences. For example, in addition to the model’s inability to discuss characterological differences or dynamic interactions between disorders and psyche, it has nothing to say about the positive side of human experience as a necessary component of health. Finally, while this complex is problematic for any psychological disorder, it becomes more so the more deeply and/or longitudinally it exists within the client, and the further from placidity, conformity, and rationality it takes her. A person experiencing an anxiety attack has a problem, a person with borderline personality disorder needs extensive management, and a person with schizophrenia is beyond the pale.

Philosophical summary and subsequent steps

The broad philosophical assumptions which form the basis for the rational-empirical model informing current scientific inquiry have given primacy to objectivity as the measure of truth as a matter of course. In so doing, it has ultimately directed research and our collective understanding of psychology into a taxonomic and symptom-based structure which will naturally prioritize biological causation and atomistic approaches to treatment. Simultaneously, the same axioms which dictate our current scientific paradigm contain implicit moral assumptions which reflexively pathologize experiences, perspectives, and expressions which are deemed “irrational,” regardless of whether they are themselves the source of distress. This interaction has led to an overall approach to psychological research and treatment which stigmatizes patients (particularly those on the schizotypal spectrum) while concurrently falling short in developing effective treatments and models due to inherent methodological flaws; despite clear evidence that current taxonomies are unstable and that the assumed biological mechanisms underlying them do not align with their framework. Moreover, given the shared genealogy of both these processes, they are self-reinforcing and inherently perpetuated through the systems and approaches they generated. Without a revolution within the paradigm (systemic schema), psychology as a whole will struggle to fully grasp its subject matter (the psyche). Much as in Piagetian models, it is the failure of schemata to account for experience through assimilation that sparks accommodation. Current evidence from within our paradigm indicates a similar process needs to occur to progress. Thus, developing a full conceptualization of schizotypy requires an act of decentralization and a re-examination of the current body of evidence as a whole if the field is to mature.

In contrast to categorical approaches, current evidence suggests that adopting a cybernetic model better captures the complexity of the phenomena, the etiology of pathological development, and ultimately offers insight into the phenomenological bases of and treatment approaches for the schizotypal population. Briefly, cybernetic models seek to map the behavior of complex self-regulating systems. The mathematician Norbert Wiener defined cybernetics as the study of “control and communication in the animal and the machine.” [46] and noted its applicability to biological systems, computer systems, and broad organizational structures such as governments. What must be understood is that within a cybernetic model, a number of interlocking processes exist within a network of mutually influential relationships. Such systems are reactive and attempt to reach equilibrium through alterations in one or more of their domains. In the case of small disturbances, a cybernetic system may merely make a minor adjustment in one domain to achieve homeostasis; however, in cases where a sufficiently large disruption occurs, the system as a whole may reorganize into an entirely novel point of balance. In such systems, feedback loops between systems are conceptualized; accounting for how over time relatively minor interactions can reinforce and strengthen each other sufficiently to cause such a restructuring. It should be noted the conceptual resonance such a framework has with Piagetian schemata, Kuhnian paradigms, and many psychodynamic conceptualizations of personality development.

With this in mind, the following sections will begin outlining relevant insights gained across a number of disciplines outlining the qualities of the proposed schizotypal population and suggesting the important factors contributing to the development of experiences such as schizophrenia.

The Schizotypal spectrum within categorical models

While schizophrenia spectrum disorders have been recognized categories of pathology for many decades, the debate about whether there is an underlying genotype or phenotype which preceded each disorder is ongoing. Indeed, there are larger limitations in the assessment of schizophrenia spectrum syndromes than any assessment’s individual construct validity. These are understandable, due to the disorder’s complex etiology and overall institutional focus on diagnosis as a starting point. Given the vast number of contributing factors both preceding and subsequent to formal diagnosis, capturing the most salient dimensions of any particular patient’s experience requires a long list of assessments and extensive clinical interviewing. That is, if there were a healthy population out of which schizophrenia spectrum disorders arise, one cannot know their characteristics except perhaps through post-hoc inference as assessments capture only symptoms of the most extreme pole of disorders. Currently, there is no comprehensive assessment covering all or even most of the domains noted through clinical research and experience. As such, developing an informed treatment plan would demand a complex exploratory phase and numerous specific follow-up assessments to achieve reliable effectiveness; however, given the stereotyped nature of current schizophrenia treatment [1,2,3,4], such a comprehensive assessment would likely be too unwieldy for clinical use, or so broad as to merely perpetuate the problem.

Despite this, the schizotypal spectrum exists implicitly as an entire chapter in the DSM (though syndromes are arbitrarily demarcated) in the temporal evolution from brief psychotic disorder through to formal schizophrenia. In contrast, the autism spectrum exists as a single F-code with level of impairment handwritten in (Levels 1–3). At the present moment, the field appears to be quite confused as to how to understand the schizophrenia spectrum. This factor remarkably complicates assessment. Despite diagnostic confusion, known empirical correlates exist with MMPI3 and Rorschach, for example; however, such correlates exist for personality traits [47], Mondal & Kumar, 2021), which may be helpful in diagnosing shizoid PD and schizotypal PD, but less helpful for a brief psychotic episode all the way through to formal schizophrenia. One’s transient state greatly impacts presentation, a second complicating factor of assessment. Thirdly, scales on the MMPI such as Scale 8 (entitled “Schizophrenia” on the MMPI2) and Restructured Clinical Scale 8 (RC8; entitled “Bizarre Ideation”) on the MMPI3 do a fine job gathering data on positive symptoms, as does the Achenbach System of Empirically Based Assessment’s “Thought Problems” subscale [48], however, negative symptoms are easier to overlook and possess a more abstract developmental quality. This is decidedly problematic given the evidence that it is negative symptoms which most influence the etiology and the treatment of schizophrenia spectrum disorders [49,50,51].

Toward issues around diagnosis the problem is even more obtuse. As the current diagnostic model requires the presentation of 2 or more serious symptoms such as hallucinations or delusions for a significant period of time and persistence of disturbance for six months [8], clinicians are caught in an orientation of triage, approaching the problem after the fact. While the DSM-5TR does imply a manner of progression from brief psychotic disorder to schizophreniform disorder and finally schizophrenia, this interpretation also focuses on the presentation of the most extreme symptoms, creates an observational perspective (altering diagnoses as various milestones are reached), and ultimately fails to properly account for the broad heterogeneity of patient presentation and differential reactions to treatment [52, 53].

It is an essential theoretical assumption that underlies the current paper that these categories more accurately represent extreme presentations along a spectrum of “schizotypy”; essentially, a spectrum which manifests diversity in presentation. Similar models already exist within psychology [54], as does the overall diagnostic mindset (e.g. identifying and treating those on the autism spectrum). It is believed that the spectrum framework better accounts for the heterogeneity of presentation and treatment outcome within the population with implications for more accurate prognosis and effective treatment. This also normalizes and contextualizes the variability and range of symptom expression. Said normalization carries not only ethical implications but also suggests dimensions of treatment that offer increased dignity and resilience to those currently experiencing the spectrum’s most distressing presentations while simultaneously opening avenues for pre-morbid interventions to prevent many otherwise healthy schizotypal individuals from experiencing said distress and its accompanying stigma. Indeed, “because the incontrovertibly psychotic diagnosis of schizophrenia fits people at the disturbed end of the schizoid continuum, and because the behavior of schizoid people can be unconventional, eccentric, or even bizarre, non-schizoid others tend to pathologize those with schizoid dynamics” [55], p. 196). Schizotypes find themselves in a double-bind: those with poor insight often have poor outcomes, and those who possess high insight are frequently besieged with depression, low self-esteem, and suicidality [56]. Thus, developing a comprehensive and destigmatizing model is an essential element in treating the population.

The presence or absence of psychosis is not an appropriate criterion measure of a distinct schizophrenia spectrum condition, nor is it deviant or divergent. Approximately 7% of the general population will have a psychotic experience within their lifetime. Of those 80% will be transitory, with only 7% going on to develop a psychotic disorder [21]. Psychotic experiences are also transdiagnostic and thus may be inappropriately conceptualized as unique to schizophrenia. “It is only when high levels of schizotypy are combined with other aetiological risk factors that an individual may be considered at risk for schizophrenia and other psychotic disorders. According to this perspective, unless high schizotypy is combined with other risk factors, it is considered neutral in regards to psychopathology” [57], as cited in [20].

The overall focus on psychosis (and, its “irrational” positive symptoms) is an axiomatic bias. However, there is empirical and clinical evidence that a population exists which is predisposed to psychotic experience and more likely to do so for much longer periods of time. If true, two questions must be answered. Firstly, what are the qualities which define this population and how do these qualities relate to psychotic experiences? Secondly, what factors (internally and externally) select some members for pathological expression?

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